Mauricio Cordeiro

A prognostic model for survival after palliative urinary diversion for malignant ureteric obstruction: a prospective study of 208 patients

To identify factors associated with survival after palliative urinary diversion (UD) for patients with malignant ureteric obstruction (MUO) and create a risk‐stratification model for treatment decisions.

Low serum testosterone is a predictor of high-grade disease in patients with prostate cancer.

OBJECTIVE To evaluate the relation between serum total testosterone (TT) and prostate cancer (PCa) grade and the effect of race and demographic characteristics on such association. METHOD We analyzed 695 patients undergoing radical prostatectomy (RP), of whom 423 had serum TT collected. Patients were classified as having hypogonadism or eugonadism based on two thresholds of testosterone: threshold 1 (300 ng/dL) and threshold 2 (250 ng/dL). We evaluated the relation between TT levels and a Gleason score (GS) ≥ 7 in RP specimens. Outcomes were evaluated using univariate and multivariate analyses, accounting for race and other demographic predictors. RESULTS Out of 423 patients, 37.8% had hypogonadism based on the threshold 1 and 23.9% based on the threshold 2. Patients with hypogonadism, in both thresholds, had a higher chance of GS ≥ 7 (OR 1.79, p=0.02 and OR 2.08, p=0.012, respectively). In the multivariate analysis, adjusted for age, TT, body mass index (BMI) and race, low TT (p=0.023) and age (p=0.002) were found to be independent risk factors for GS ≥ 7. Among Black individuals, low serum TT was a stronger predictor of high-grade disease compared to White men (p=0.02). CONCLUSION Hypogonadism is independently associated to higher GS in localized PCa. The effect of this association is significantly more pronounced among Black men and could partly explain aggressive characteristics of PCa found in this race.

Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes

BACKGROUND Robot-assisted laparoscopic radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP which preserves the nerves and vascular structures anterior to the prostate aiming to optimize functional outcomes. OBJECTIVE To present oncological and functional results of a modified technique for RARP. DESIGN, SETTING, AND PARTICIPANTS Prospective, noncontrolled case series including 128 consecutive patients undergoing RARP performed by a single surgeon (R.F.C). SURGICAL PROCEDURE RARP with retrograde release of the neurovascular bundle and preservation of dorsal venous complex. MEASUREMENTS Potency was defined as a Sexual Health Inventory for Men score of ≥17; continence was defined as use of no pads. Oncological results analyzed were positive surgical margins (PSM) rates and biochemical recurrence (BCR)-free survival. BCR was defined as prostate-specific antigen >0.2ng/ml. Complications were graded according to the Clavien-Dindo classification. RESULTS AND LIMITATIONS Median patient age was 63.5 yr. Median skin-to-skin time was 78min. Median length of hospital stay was 1 d, with seven patients (5.5%) hospitalized for more than 24h. Median intraoperative bleeding was 200ml and two patients required postoperative blood transfusion (1.6%). Four patients (3.1%) had grade ≥3 complications. Biochemical recurrence (BCR) occurred in nine of 128 patients (7%) and median time to BCR was 6 mo. Overall PSM rate was 13.3% (17 of 128 patients). PSM rate was 9% among patients with pT2 disease (8/89) and 27% in patients with pT3 (9/38). Continence was reached immediately in 85.9% of the patients and 98.4% were continent at1 yr. At 1 mo postoperatively, 60 patients were potent (53%), while 98 patients among 113 (86%) were potent 1 yr after surgery. A limitation of this study is that it was a noncomparative study. CONCLUSIONS Retrograde release of the neurovascular bundle with preservation of dorsal venous complex during RARP is safe and associated with excellent oncological and functional outcomes. Future comparative studies are needed. PATIENT SUMMARY Robot-assisted radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP aiming to preserve the nerves and vascular structures anterior to the prostate. We evaluated 128 consecutive patients with clinically localized or locally advanced prostate cancer undergoing RARP with our modified technique of retrograde release of the neurovascular bundles with dorsal vein sparing. We have shown that this technique is safe, effective and associated with early recovery of continence and sexual function after surgery.

PD66-01 RENAL CELL CARCINOMA WITH PERIRENAL FAT INVASION: IS PARTIAL NEPHRECTOMY AS GOOD AS RADICAL SURGERY?

e16056Background: Partial nephrectomy (PN) is the standard of care in the management of cT1a tumors, while radical nephrectomy (RN) is indicated in more advanced tumors. Recent studies provided evi...

V3-06 CONVENTIONAL LAPAROSCOPIC RADICAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY

RESULTS: Robotic left nephrectomy and level II caval thrombectomy was performed successfully via a single-dock, supine approach. This method yielded excellent and early access to the IVC and left renal hilum, and allowed for concomitant nephrectomy/LND without re-positioning. Total operative time was 420 minutes with 330 minutes robotic console time (174 minutes for exposure, 27 minutes IVC clamp time, 84 minutes for nephrectomy/LND). EBL was 500cc without need for peri-operative transfusions and no intraoperative complications. Length of stay was 5 days and no major perioperative complications were noted. Outcomes compare favorably to previously reported robotic caval thrombectomy procedures employing the lateral approach. CONCLUSIONS: We demonstrate successful robotic left nephrectomy with Level II caval thrombectomy using a supine, singledock approach. To our knowledge, this is the first description of this approach for robotic caval thrombectomy. In appropriately selected patients, this versatile approach allows for rapid caval control, bilateral renal hilar access, and obviates the need for patient repositioning.

MP04-17 BLOOD-BASED BIOMARKERS AS PREDICTORS OF ONCOLOGIC OUTCOMES FOR NON-MUSCLE-INVASIVE UROTHELIAL BLADDER CARCINOMA

INTRODUCTION AND OBJECTIVES: Our group has previously demonstrated that blood-based tumor markers can be useful clinical outcome predictors for non-muscle invasive urothelial carcinoma of the bladder (UCB) Our aim in this study is to further evaluate the predictive value of CEA, CA 19-9 and CA 125 on disease recurrence and progression. METHODS: We prospectively included 328 consecutive patients between February 2008 and August 2014 to measure preoperative serum levels of CEA, CA 19-9 and CA 125 before first transurethral resection of the bladder (TUR). Institutional Ethical Committee approval was obtained prior to this study. Patients diagnosed with pT2 UBC were excluded (42), leaving 286 patients for analysis of recurrence or progression. After first TUR, patients were followed with routine cystoscopy, cytology and ultrasound every 6 months. All patients with non-muscle invasive (NMI) bladder cancer with high-grade disease, previous recurrence, carcinoma in situ (CIS) or T1 received induction and maintenance intravesical BCG. RESULTS: We found that CEA and CA 19-9 levels were significantly higher in patients who had either tumor recurrence and/or progression compared to those who had no UBC recurrence during follow-up (p1⁄40.02; p1⁄40.03). As we had found previously, however, CA 125 levels did not differ between the two groups (p1⁄40.42). Overall, mean CEA level was 2.1 (0.2-12.8), CA 19-9 was 17.1 (0.4-189.9) and CA 125 was 12.5 (1.2-103.9). In patients who presented tumor recurrence and/or progression, mean CEA was 5.5, mean CA 19-9 was 21.0 and CA 125 was 13.8, while in the non-recurring group, mean CEA was 3.1, mean CA 19-9 was 11.1 and CA 125 was 11.3. Mean follow-up was 4.9 years. Patients were 70.3% males (201); 63.3% (181) of patients had pTa at first TUR. Concomitant carcinoma in situ was present in 25 cases (8.7%). CONCLUSIONS: Biomarkers utilized in routine follow-up of other malignancies, such as CEA and CA 19-9, can also be included in UCB management, since it proved able to distinguish a higher risk group of patients that could be managed accordingly. Future studies may add these blood-based tumor markers to a predictive model and validated in a larger cohort. Although CA 125 was not significantly associated with oncologic outcome, further studies are required before excluding this potential biomarker in UBC.

MP90-07 THE PHENOMENON OF EPITHELIAL-MESENCHYMAL TRANSITION IS ASSOCIATED WITH THE PROGRESSION OF PROSTATE CANCER

platform. Affymetrix Oncoscan analysis was used to determine genome-wide copy number and loss-of-heterozygosity (LOH) profiles. Whole transcriptome analysis was performed using Affymetrix GeneChip Human Transcriptome Array 2.0. RESULTS: We generated full exome sequences to determine the impact of acquired somatic mutations driving lethal and recurrent bone metastatic CRPC, as well as impact of treatment first with androgen deprivation therapy (ADT), then additional radiation plus docetaxel and, lastly, abiraterone plus cabazitaxel from sequential surgeries in a single patient. We also sequenced the whole exome of PCSD1 intra-femoral xenograft tumors to determine the impact of in vivo xenograft models on the exomic integrity of prostate cancer bone metastasis. Sequence analysis has identified SNVs, small insertion and deletions, translocations and additional gene rearrangements that are shared as well as unique to each bone metastatic sample. Integration of exome sequencing, CNV and microarrays revealed activation of WNT5a in prostate cancer bone metastases. CONCLUSIONS: This is a whole exome and transcriptome report on a unique set of samples from one patient: blood (germ line), primary tumor, surgical bone metastasis sample #1 after ADT, bone metastasis #2 after ADT, radiation and docetaxel, bone metastasis #3 after abiraterone, radiation, plus cabazitaxel. Analysis of surgical prostate cancer bone metastases at different stages of treatment and progression in this patient provides a foundation to profile genomic diversity in recurrent bone metastatic prostate cancer. Mutations and activation of Wnt5a are being tested int the matched patient derived xenograft, PCSD1.

PD48-04 PROSPECTIVE RANDOMIZED TRIAL COMPARING OPEN TO LAPAROSCOPIC PARTIAL NEPHRECTOMY, INTERIM ANALYSIS. (NCT01809119)

patients cT1 to pT3a upstaging treated with either partial nephrectomy (PN) or radical nephrectomy (RN); however to date no studies have evaluated comparative outcomes for PN versus RN. We sought to characterize outcomes for cT1 to pT3a lesions treated with these modalities. METHODS: Our institutional renal mass registry was queried for patients with cT1 renal tumors upstaged to pT3a RCC. Cancerspecific survival and recurrence-free survival were evaluated using the Kaplan-Meier method and multivariable Cox proportional hazard regression. RESULTS: A total of 2,034 patients with a cT1 renal mass underwent extirpative surgery and 174 (8.5%) were upstaged to pT3a RCC. Upstaging was due to segmental renal vein invasion in 43 (24.7%), perinephric fat invasion in 100 (57.5%), and/or sinus fat invasion in 40 (23.0%). During a median follow-up of 43 months, upstaged patients had a greater risk of death from RCC (HR 3.3, 95%CI 1.7-6.7, p 0.001) compared to non-upstaged patients. Of upstaged patients, 56 (32.2%) underwent PN and 118 (67.8%) underwent RN. On univariate analysis, PN was associated with superior CSS (p < 0.001) and RFS (p<0.001). However, on multivariable analysis, adjusting for tumor diameter, nuclear grade and tumor necrosis, there was no difference in CSS (p 1⁄4 1.0) or RFS (p 1⁄4 0.3) between interventions groups. CONCLUSIONS: Patients with cT1 renal tumors upstaged to pT3a RCC have worse oncologic outcomes than non upstaged patients. With intermediate-term follow-up, PN appears to offer equivalent oncologic outcomes to RN while also conveying the benefits of a nephron-sparing approach.

A prognostic model for survival after urinary diversion for malignant ureteral obstruction: A prospective study of 208 patients.

102 Background: To determine prognostic factors and create a model for risk stratification in patients with malignant obstructive uropathy. METHODS We prospectively collected clinical and laboratory variables of 208 patients who underwent palliative urinary diversion by ureteral stenting or percutaneous nephrostomy between January 2009 and November 2011 in two tertiary care university hospitals, with minimum 6 months follow-up. Inclusion criteria were age>18yr and malignant urinary obstruction confirmed by computed tomography, ultrasound or magnetic resonance imaging. RESULTS Median survival after urinary diversion was 144 days. At the end of the study 164 patients died, 44 (21.2%) during the urinary diversion hospitalization. There was no difference in overall survival between the 2 types of diversion (p=0.216). The number of events related to malignant dissemination (≥4) and ECOG index≥2 were associated with shorter survival in multivariable analysis. Using these 2 risk factors (RF), patients were divided into 3 groups: favorable(no RF), intermediate(1RF) and unfavorable(2RF). The median survival at 1, 6, and 12 months was 94.4%, 57.3% and 44.9% in the favorable group, 78.0%, 36.3%, and 15.5% in the intermediate, and 46.4%, 14.3%, and 7.1% in the unfavorable. There were differences in survival profiles of the 3 groups (p<0.001). CONCLUSIONS Our stratification model may be useful tool to determine whether urinary diversion procedures are indicated in patients with malignant urinary obstruction.